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8.17 pm
Dr. Howard Stoate (Dartford) (Lab):
It gives me great pleasure to follow the right hon. Member for North-West
Hampshire (Sir George Young), who talks with great authority about smoking and comes up with extremely important points. As he rightly noted, he is well ahead of his Front-Bench colleagues on the issue, and all power to him. I am sure he will support the measures, as he has promised to do.
One of the advantages of a health Bill from my point of view is that it gives me the opportunity to rehearse a well-worn mantra the House has heard many times—“As a practising GP”. I do not say that lightly, because it is a serious point. I am proud to be an NHS general practitioner. I am very proud indeed to be on the front line, implementing some of the policies that I have helped my Government to pass over the past 10 years or more. That is an important point because it genuinely informs my work in the House—on the Health Committee, which my right hon. Friend the Member for Rother Valley (Mr. Barron) chairs so admirably; as chair of many all-party Back-Bench groups that do a lot of work behind the scenes; and in debates in the Chamber.
Ultimately, the proof of any Bill is in its implementation. Our debate and rhetoric in the House do not matter; what matters is how a Bill, when it becomes an Act, affects the lives of people out there. When a health Bill has been through all its stages in this and the other place and has become law and is implemented, I am in a position to judge at first hand how it affects the running of the health service and its direct impact on the health of my patients.
As we have heard, the Bill sets up an NHS constitution—an idea I thoroughly support—which will make a big improvement in the way patients engage with the NHS. I hope it will improve the way they use the NHS so that they get much more from the service, which of course they pay for.
Another aspect of the Bill is that it implements the parts of the NHS next stage review, so admirably run by Lord Darzi in the other place, that require primary legislation. They include provisions on the constitution, quality accounts and direct payments, as we have heard this evening. Despite great progress, the NHS still faces many pressures when it comes to achieving the goals set out in the NHS next stage review. We are a long way away from where we would like to be on the issue; we still have a considerable distance to travel. The next stage review makes it clear that to move forward, the NHS needs to spend time looking at how it can provide a more integrated service for its patients. For example, the review mentions piloting new “integrated care” organisations that bring together health and social care professionals from a wide range of organisations—community services, hospitals, local authorities and others—depending on local needs.
The review also said that stronger support will be given to practice-based commissioning by providing incentives for a wider range of clinicians to get involved. That is an important point. That would enable GPs to work alongside other community clinicians and specialists working in hospitals to develop more integrated care for patients. I strongly support that drive towards more collaboration between health care professionals. I have always believed in the effectiveness of the NHS, but it has been severely hampered over the years by the chronic
inability or refusal of primary and secondary care professionals to work genuinely in partnership.
In the past, GPs and hospital specialists rarely engaged with each other in any meaningful way, while the relationship between GPs and community pharmacists was virtually non-existent in most parts of the country. Importantly, the new constitution emphasises the fact that the modern NHS is an integrated organisation that requires all its constituent parts to work in concert for the good of its patients, and that is long overdue. Although progress is being made in that area, it is clear that in parts of the NHS we still have a long way to go if we are to get the level of integration that we need.
One of the main challenges is information technology, and that, in the main, is what I want to talk about tonight. Connecting for Health, which started its life as the national programme for IT, has been mired in controversy since its very inception. Problems with software packages, and to do with access and security standards, together with the woeful failure of its commissioners to appreciate the complexity and scale of the undertaking, have caused severe delays in the roll-out of the NHS care records service, which, of course, is the centrepiece of the entire programme. Until we resolve that issue, we will never achieve the degree of integration that the next stage review envisages.
As someone who does some general practice, I have encountered my fair share of IT problems over the years. The much-vaunted choose-and-book system, which is designed to link 30,000 GPs with almost 300 hospitals across the country, is a case in point. When it works, it is wonderful. It allows me to search the entire NHS database for clinics that provide the service that my patients require. It allows the patient to sit with me and choose which of those clinics they wish to be referred to. They can trade off factors such as parking convenience, the knowledge of a particular consultant, particular specialties within a department, and the ability to visit a hospital near where their family lives. All those wonderful things, which in the past were virtually impossible, are now possible with choose and book. A patient could say, “I’d much rather be seen in Birmingham, doc, because my sister lives there”—not a problem. As long as the option comes up on the choose-and-book website and meets the tariff requirements, I can book an appointment in Birmingham for them. When the system works, it works marvellously well.
David Taylor: I spent 30-odd years, from the age of 19, working in the IT industry in the public sector before coming to this place in 1997. One of the problems in the public sector is that the outsourcing mania that there has been, particularly in the civil service, over a very long period has deprived and denuded Government structures of people who can act as intelligent clients. In other words, the Government are more susceptible to the wiles, charm and public relations of snake-oil salesmen, who are fairly common in the software industry. That is the problem. Intelligent clients can spot where the problems are, and the problems that my hon. Friend mentions were not spotted in the early days of Connecting for Health.
Dr. Stoate:
I bow to my hon. Friend’s great judgment on the issue. He is a real expert on IT, particularly in the public sector, and I defer to him. I sometimes wish
that there was some more snake oil poured into my computer; it might then work a bit faster. As things are, it cranks along.
Things are not always straightforward, and I shall give some examples. Only about half of all services in my area are available on choose and book, and not all of the services that are supposed to be bookable can be booked. A couple of months ago I had a patient with a wrist problem, so I went on to choose and book. We found a hand and wrist service—ideal for the job—just down the road from my surgery. “Perfect,” one would think. However, the next day when the patient came back to see me I found out that the hand and wrist service did not do hands or wrists. I am not making that up; it actually happened. I had to start again from the beginning. It meant another wasted appointment, a baffled patient, and bemused staff. Eventually, we sorted the matter out with a different hospital.
The choose-and-book server has the interesting habit of throwing the user out at 5 o’clock on a Friday evening. That is not even outside core hours, let alone compatible with the concept of extended hours, which most GP practices across the country are now embracing. When, at 10 minutes past 5 o’clock, one says to a patient, “I’ll just book you a choose-and-book appointment,” only to find that the server has gone off and will not come back on again until Monday morning, it is, to say the least, irritating. I have never understood why it happens, but it happens very frequently—far too often to be just coincidence.
Even more seriously, it is apparent to me that some acute trusts have tried to get around the 18-week service target simply by saying to the patient, “There are no appointments available.” It is a great irritation when one has given the patient a print-out and told them to phone up for the appointment of their choice, for them to be told that there are no appointments whatever. The patient then comes back to see me the following day, which means another wasted appointment. It transpires that hospitals can manipulate the 18-week target if they simply stop offering any appointments. If they do not offer appointments, they cannot miss the target. That might be wonderful from the hospital accountants’ point of view, but it is pretty miserable from the point of view of the GP and the patient.
In some areas, however, choose and book has been a runaway success. In Barnsley, for example, about 75 per cent. of all GP referrals are made through choose and book. The key to Barnsley’s success is strong leadership from the local primary care trust, which has ironed out the technical glitches and professional resistance and persuaded the secondary care trust to get behind the service and make it patient-friendly. There is no reason why that should not be replicated across the country. There is no shortage of innovative care models involving communications technology that work at local level. In Sheffield, for example, trials are running of a virtual desktop that enables clinicians to access patient records using interactive bedside systems. That reduces the need for staff to keep logging in and out of computers, and cuts down on the endless administrative paper trail.
It is when we try to create IT systems that are capable of being used in more than one place by more than one type of health care professional that we run into problems. As chair of the all-party pharmacy group, one of my biggest frustrations—I am sure that it is shared by the
hon. Member for Romsey (Sandra Gidley), who is also an officer of the group—is that pharmacists are not being given the IT resources that they need to allow them to make full use of the new responsibilities laid out in the new pharmacy White Paper. If they are not connected and integrated, they simply cannot maximise the use of their skills. That is a potentially dangerous problem.
If we are to expect pharmacists to prescribe as well as to provide front-line clinical services, as they should, it is absolute nonsense for them not to have read-write access to the patient clinical record. I shall give an example, because the problem is serious. This morning I did a surgery. I saw a patient with an infection and I wanted to prescribe her an antibiotic. I asked her if she had any allergies—“No, doc, I can take anything.” So I typed in the first antibiotic of my choice. A message popped up on the computer saying, “Warning. Patient allergic to this drug.” So I said to her, “It says on the computer that you’re allergic to this drug.” “Oh, yes,” she said. “That’s right.” I asked her if there were any other drugs that she was allergic to—penicillin, for example. “Oh, no, doctor, definitely not.” So I typed in “Penicillin”, and the message on the computer came up to tell me that she was allergic to penicillin. I said to her, “It says here that you’re allergic to penicillin.” “Am I, doc? Goodness me. Actually, come to think of it, there are quite a few drugs I can’t take,” which she had completely forgotten to tell me about a few minutes before.
Woe betide the hapless pharmacist who came across this lady and who might decide to prescribe antibiotics for her, having been told by her that she did not have any allergies, only to find out the hard way that she did. That is a mistake that should not happen. Had the pharmacist had access to the patient record, that would be easily dealt with. It is no longer credible to say that pharmacists cannot have access to the patient care record.
Pharmacists are doing medication use reviews in huge numbers. At present the reviews come back to the practice in paper form. Most of them are no longer handwritten. At least they are now computer-generated, but a piece of paper in the GP’s surgery is as much use as a chocolate Easter egg in hell. It is no use whatsoever, because the information on it has to be scanned, taken off that printed record and entered into the patient record, and in many cases that is not going to happen. So the usefulness of the MUR is severely hampered by the fact that if it is not in electronic form, it does not integrate into the patient record. It needs to do so.
I move on to the commissioning of services. Progress in commissioning of new providers has also been very mixed. Many PCTs have a great record when it comes to stimulating the market and commissioning services from community-based providers, such as pharmacists. I am therefore pleased that the Department of Health has taken steps to address this by encouraging PCTs to ensure that there is appropriate pharmacy input in PCT decisions. I hope that this will improve awareness within the PCT. However, it is also clear that the introduction of practice-based commissioning has helped to make more effective use of resources, and is bringing care closer to home for patients.
My patients, for example, are now able to take advantage of community cardiology services. This means that I, as a GP, can book a patient into a community cardiology
service for a 24-hour ECG or an echocardiogram within a few days, which in the past would have taken several months. Now it can be done much more easily and quickly, with the patient travelling far less distance to receive that service. It has also reduced the cost by about 30 to 50 per cent. Similarly, those with muscular-skeletal conditions are now able to use a local access clinic, where the patient with a back, hip or knee problem can be triaged within a week or two and passed on to the appropriate consultant specialist without the need for extensive waiting and with a much more efficient service than we ever had before.
MRI scans are available to open access by general practitioners. This is a huge advantage. Not only can I now get an MRI scan for a patient within about two weeks of referral, but there are several other benefits. First, the patient does not have to travel, because it is a local service. The machine is mobile and can be moved from surgery to surgery. Secondly, the waiting time is extremely short—only a couple of weeks. Thirdly, GPs can maximise their own clinical skills by making much more use of investigations themselves, and fourthly and possibly more importantly for the NHS, that reduces the need to refer patients to a consultant. This means that there is less pressure on hospitals and gives them more opportunity to maximise the skills that hospitals can provide, which others cannot. It takes the pressure off them and allows them to get on with their job.
The challenge now is to ensure that these examples of best practice are replicated right across the country. I believe we can do that. I have provided many examples this evening to show that that can be done. I visited one of my pharmacy colleagues today, Bipin Patel, who runs a pharmacy in the middle of Bexleyheath, where my practice is based. I was talking to him about how we can reduce prescribing and dispensing errors, particularly in the light of an inquiry that the all-party pharmacy group is to carry out in the near future on dispensing errors. He read out to me a prescription with a very ambiguous message on it. He did not have access to the patient’s record, so he had to phone the GP and double check what the GP meant, causing delay and problems for the patient. That is another example in which access to the patient record would be a good thing.
The NHS constitution, which I thoroughly support, allows a review only after a 10-year period. However, it provides for the handbook to be considered every three years and the effects on patients and staff every three years. Perhaps my right hon. Friend will consider the matter in the course of his deliberations, or perhaps it could be discussed in Committee and on Report. Can we ensure that the NHS constitution is reviewed rather sooner than 10 years? That is too long a time. I would advocate that it be reviewed after three years, at the same time as the NHS constitution handbook and the effect on staff. Will my right hon. Friend address that point?
8.33 pm
Dr. Richard Taylor (Wyre Forest) (Ind):
It gives me great pleasure to follow the only practising doctor in the House of Commons, the hon. Member for Dartford
(Dr. Stoate). I have to admit that his speed of delivery sometimes leaves me feeling rather breathless, but I admire his turn of phrase.
I welcome the new Secretary of State to his position. I remember arriving in 2001 at exactly the same time, and sitting on the Health Committee for at least two years with him. Since then, his rise has been somewhat more meteoric than my own rather pedestrian progress from this very same Bench. However, I welcome him to his post and echo what the right hon. Member for North-West Hampshire (Sir George Young) said: to have mastered that brief in an extremely short time was pretty impressive.
First may I say, as I have said many times, that there have been great improvements in the NHS, particularly on waiting times and on cancer and cardiac services? However, in some respects, all is still not yet well. The results of patient satisfaction surveys, to which reference has been made, are impressive, but they miss out some matters on which the health service is not working quite so well, and I am afraid that I must draw the Secretary of State’s attention to one or two of them. We all know about Mid-Staffordshire, the failure of leadership and the failure of some staff to deliver quality or even safe care, but I have a horrible suspicion that that lack of quality, especially relating to dignity, compassion and communication, is more widespread. My hope is that the NHS constitution can address and alter the situation, but I shall give two examples of matters that have come across my desk recently. I referred to the first in a Westminster Hall debate on 14 May, but, as the Minister who heard me then is no longer in the same post, I shall repeat some of the points that I made on that occasion.
I read out a letter, in its entirety, from an elderly couple who had lost their only son at 31 years old. I shall not put the House through the whole letter, but I shall read one or two extracts just to demonstrate that things are not all well. Those elderly parents said:
“We would arrive to see him, to find him lying in a soaking wet bed, or worse.”
“Our son had an infection under his nails and was unable to pick things up. This the staff knew about, so why were pills left in the little plastic cup...from the morning and lunch time. Maybe it was because he had no water jug or cup so he had nothing to drink.”
“Lots of working people have long stressful days, and I know people who went into nursing as a vocation but sadly those days have gone. When someone is training for this job, I’m sure they must learn what is expected from them, and the meaning of the word nurse means to take care of and hopefully give a person dignity, which sadly our son didn’t have at times.”
“We hope that if either of us should need to go into hospital in the future, that the cleaners do what they're supposed to do and our right to dignity is upheld.”
I saw that couple in my advice surgery last Friday. They are still so upset that they cannot face putting in a formal complaint or allowing me to name them. In my view, formal complaints are not much use; they lead just to apologies—not, very often, to any particular change. Even in Stafford, the Healthcare Commission upheld many complaints, but the board either took no notice or was not even aware of them.
In a second example, which was also raised in my advice surgery last Friday, a qualified nurse told me about her mother, who is 88 years old. She fell with a suspected hip fracture and was taken to an accident and emergency department at 7 o’clock. The family arrived at 10 o’clock, but she had not been assessed or seen. Eventually, she had X-rays and was admitted for review because no trauma and orthopaedics team was on duty until the next day.
The daughter, a nurse, felt that there could not be a fracture, because her mother was pain-free and had good movement. Nevertheless, she had to be admitted so that she could be seen by an expert. She had gone six hours without fluids, there were no beds and she remained on a couch in the accident and emergency department. The next day, surprise, surprise, there was no fracture, but she was confused and immobile. When her daughter asked for a glass to give her water, she was told that the tumblers were only for tea, not for water. But this really capped it, the daughter says:
“I was told by the staff nurse that she was dehydrated, confused and with a probable urine infection, but that it was not the nurses’ role to make her drink anything.”
The last straw came when the patient went to another hospital for rehabilitation; it was discovered that she had been having a large, wrong dose of a sedative in the morning instead of at night.
Those are two examples that show that all is not going well. I hope that the constitution can do something about such problems. Not that long ago, when I was walking to the railway station, I saw a member of staff picking up fag ends outside the station. He said that it was easy to change policies, but very difficult to change people. I thought that extraordinarily astute.
I turn to some of the rights under the NHS constitution. Under the heading “Respect, consent and confidentiality”, it states:
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